An 11-year-old female was referred to the pulmonologist with a several month history of daily coughing, that began after a cold.
The cough occurred at least every 3 minutes with flares of coughs 3 times/minute.
The cough is described as a dry “goose-honk.” The patient states that she feels a tickle in her throat, feels strange, and then coughs.
The cough occurs only during the day especially when she first rises and it does not interfere with her school work.
She has been tried on albuterol and inhaled steroids without relief. She has had a chest radiograph and ‘other tests’ which were normal according to her mother, including seeing a local psychologist.
The past medical history is negative.
The family and social history is positive for an aunt who coughs when very nervous. There are no neurological, psychiatric or learning problems in the family.
There has not been any recent family stressors and she continues to do well in her academically gifted program at school. She has been getting along well with her family and friends also.
The review of systems is negative including tics, throat clearing or vocalizations and other nervous habits. She has had no colds or other illnesses recently.
She has had no fevers, weight loss, sweats, or rashes.
The pertinent physical exam shows a healthy child with normal vital signs, height and weight for age. Her HEENT and pulmonary examinations are normal, but she is noted
to make a “hump” sound followed by a cough that occured multiples times during the examination.
The work-up included reviewing the previous testing and normal pulmonary function tests.
The diagnosis of a habit cough was made.
The physician explained the diagnosis, commenting that at this time it did not appear that she has or had any tics or Tourette syndrome features nor did she seem that she had a great deal of anxiety.
He explained the cycle of a cough irritating the pulmonary structures that then leads to a cough, etc., and the need to break the cycle.
A cup of water was given to the patient and she was told to take a small sip whenever she felt the need to cough. She did this, and even within the few minutes that the physician was speaking with the family, everyone noted a decrease in the frequency of the cough.
The patient and family were instructed to continue this treatment for several days and to call the clinic back if the cough was not improving.
They were also told that speech therapy to improve breath support could also be helpful for some patients. Before leaving
they were also cautioned that should other behaviors such as a tic or increased anxiety occur to contact their local physician.
Cough is a common complaint in the outpatient arena. The literature is inconsistent with the terminology used to define “habit cough,” “psychogenic cough” or “nervous tic,” especially in children.
The literature generally agrees that a habit or psychogenic cough implies a non-organic etiology and one of exclusion.
A recent guidelines noted that a habit cough is often associated with a throat-clearing noise” and before the diagnosis “???can be accurately made, biological and genetic tic disorders associated with cough must be ruled out.”Psychogenic cough is often described as having a ‘honking’ nature. Some literature suggests that patients do not cough at night, but this is not consistent. Multiple other criteria for diagnosis have been suggested but their actual usefulness is not known (e.g. increases or decreases with stress or pleasurable activities, indifference to the cough, attention seeking, cough preceeded by upper respiratory tract infection, etc.)
The guidelines recommend that the “??? diagnoses of habit cough or psychogenic cough can only be made after tic disorders and Tourette syndrome have been evaluated and the cough improves with specific therapy such as behavior modification or psychiatric therapy.”The guidelines do not suggest a specific evaluation and note that an extensive workup may actually be harmful to children as it could require general anesthesia or other invasive testing.
It appears that habit cough or psychogenetic cough are primarily a pediatric and adolescent disease and few cases are reported in the adult literature.
Suggestion therapy is the main treatment and can be applied in slightly different ways.
In one study, elements of one 15-minute session of suggestion therapy that was successful with long-term relief of symptoms included:
1. Expression of confidence by the physician that the patient could stop the coughing
2. Explaining the cough as a viscious cycle of irritant-cough-irritant-cough, etc.
3. Encouraging cough suppression to break cycle – holding the cough back, use of water, etc.
4. Expressions of confidence by the physician that the patient was developing the ability to supress the cough
5. When some cough suppression is observed, noting “You are beginning to feel you can resist the urge to cough aren’t you?”
6. Stopping the session, by asking several times “Do you feel you can now resist the urge to cough?” which is asked after the patient has gone more than 5 minutes without coughing.
Other treatments have included self-hypnosis, wrapping a bedsheet around the chest to help decrease cough and other behavioral modifications. Cough suppressant medication are generally not used.
Questions for Further Discussion
1. What are the Diagnostic and Statistical Manual of Mental Disorders criteria for tics and Tourette Syndrome?
2. What is the differential diagnosis for a chronic cough in a child?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MEDLINEplus for this topic: Cough
and at Pediatric Common Questions, Quick Answers for this topic: Cough
To view current news articles on this topic check Google News.
Lokshin B, Lindren S. Weinberg M. Koviach J. Outcome of Habit Cough In Children – Treatment with a Brief Session of Suggestion Therapy. Ann Allergy. 1991:67;579-582.
Irwin RS, Glomb WB, Change AB. Habit Cough, Tic Cough, and Psychogenic Cough in Adult and Pediatric Populations: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 2006;129;174-179.
Fitzgerald DA, Kozlowska K. Habit Cough: Assessment and Management. Paediatric Respiratory REviews. 2006:7;21-25.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competency performed.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
June 26, 2006